By Helen Carter
Every six minutes in Australia a person is diagnosed with dementia. There are nearly 1,700 new cases and 25 deaths a week from this devastating progressive illness.
As Australia’s population ages, more people will be affected. The number is expected to triple in the next 35 years and optometrists will increasingly be providing eye care to patients who are affected.
The approaching high incidence of dementia has prompted Australia’s health ministers to designate dementia as the ninth National Health Priority Area.
The condition presents unique problems for health-care practitioners providing consultations and treatment for these patients.
Melbourne psychiatrist Dr Ruth Kipen, a specialist in the Psychiatry of Old Age, has many dementia patients and is familiar with eye-care issues as she shares professional rooms with her husband, cataract surgeon Dr Mark Cherny.
|Kipen: People with dementia can resist personal examination
due to fear or behavioural features of the illness
‘Poor vision can exacerbate and aggravate behavioural problems in dementia, making patients more confused, uncertain and bewildered so it is really important to ensure their senses are in good working order,’ she said. ‘Impaired vision can also increase falls risk.’
Queensland optometrist Helen Venturato has provided optometric services to patients with dementia, has a sister working in the field and two of her grandparents suffered from dementia.
She believes guidelines are needed to help advise optometrists in this delicate area. ‘We don’t have guidelines advising us when to notify a GP, what we should say, and what our moral and legal obligations are to report to a GP,’ she said.
‘We learned nothing about dementia patients when I studied optometry. ‘This population is going to grow significantly and there is a big gap in education for optometrists about it. The rising incidence of diabetes will also increase vascular dementia.’
Referral for early cataract removal is another way optometrists can help dementia patients.
‘Good sight may help slow the progression of dementia,’ Ms Venturato said. ‘Sometimes optometrists might say the patient has early cataracts, let’s wait until vision is 6/12 but dementia specialists would say have cataracts removed as soon as possible, at 6/7.5 or earlier, while the patient still has the cognitive function to understand what is happening,’ she said.
‘The dementia will only get worse and it won’t be any easier to undergo surgery.’
Many of Dr Kipen’s dementia patients have had cataract surgery. She says surgical intervention in mild to moderate dementia is important while the patient can give informed consent.
Ms Venturato says that in early stages of dementia, many are aware that something is going on and that they are starting to lose their memory but are in denial because they are aware of the implications. Others have no insight into their impairment.
‘Anyone in practice for a long time sees patients over the years and sees those changes,’ she said.
‘Optometrists are in a delicate position. They may see changes and if they have a good rapport with the patient, might be able to ask if everything is okay, get them talking about it and suggest they see their GP because the earlier a diagnosis is made, the better.
‘We can send a report to their GP saying we have noticed some behaviour and memory changes which may be suggestive of other pathology, as a matter of good record-keeping and good relationships with the GP.’
Venturato: When a dementia diagnosis is made, the patient
Ms Venturato says that when a dementia diagnosis is made, the patient should seek dental and optometric treatment as soon as possible because those treatments become more difficult to deliver as the dementia progresses.
‘People with early dementia can still give a subjective response, but are often good at confabulating—what they cannot remember they fill in and it sounds legitimate, so for the presenting complaint and general history, they may not be reliable and you may need to get a relative or carer to come in with them to confirm,’ she said.
Getting objective measurements from the autorefractor or retinoscope is important in the early stages.
‘For more advanced dementia, you will need to rely on carers for information,’ Ms Venturato said.
‘The optometrist should be alert to the fact that it may be a naming rather than seeing issue. Sometimes patients forget what letters are called so cannot name them in a Snellen chart.
‘Instead of asking patients what letter they see, optometrists could put items on a tray and ask the patient if they can pick something up, or point to the blue object, rather than saying “pick up the pen”, in case they forget what a pen is.’
Posture and behaviours also provide hints about eyesight. If the patient’s head is right down on the tray looking for something, their eyesight may not be good.
Unusual behaviour such as becoming withdrawn, confused or disoriented, being clumsy or falling more, bumping into things, holding things close, or being startled by noises or people approaching may be a reaction to sight loss.
‘This is part of the assessment of what skills they have and have lost, and enables the optometrist to work within the set of skills they have,’ Ms Venturato said.
Dementia patients may not be aware they have poor vision so consolidating their history from a relative or carer is important.
‘It is better if the patient can tell you so always talk to them first and get as much information as possible from those with early dementia,’ Dr Kipen said.
‘If dementia is more advanced, you may need to ask their carer or relative.’
Dr Kipen says the visual cortex may be affected so the patient may warrant a referral to an ophthalmologist for further assessment and possible brain MRI.
‘Dementia is chronic brain failure which affects personality, intellect and behaviour. It is a complex disease but every patient is different and will have different symptoms so it is hard to generalise. It is a delicate and sensitive area,’ she said.
‘Sometimes it is challenging and people with dementia can resist personal examination due to fear or behavioural features of the illness.’
Dr Kipen suggests health professionals ask the patient if it is possible to discuss their condition with other health practitioners so all can work together to help them. This includes getting consent from the patient, their relative or carer when conducting optometric consultations in nursing homes on vulnerable patients.
Optometry’s role in dementia may expand in the future as some research indicates that amyloid plaques accumulate in the eye 10 to 20 years before Alzheimer’s Disease is diagnosed.
Eventually, optometrists may be at the forefront of diagnosing dementia and by then, prevention may be possible.
Other evidence suggests macular degeneration and Alzheimer’s share a common pathogenesis and suggest an association between AMD and reduced cognitive function.
TIPS for giving care
- Check with a carer or relative regarding an optimal time for an appointment. Dementia patients are often less troubled in the morning but check the time when they are at their best.
- These consultations can be time-consuming so consider allocating a double appointment as patients can be sensitive to time pressure and become anxious.
- Make the patient comfortable, greet them warmly, shake their hand, be kind and caring.
- Keep an open line of communication to the patient’s GP.
- Try to get patients to bring a relative or carer to consultations.
- Say ‘This is what we can do to keep your eyesight good and make things easier for you.’
- If patients get confused about which glasses to wear, consider labelling them for reading and distance.
- For people in a nursing home, their name on the spectacle arm may help. Patients are often found wearing other people’s glasses. Assess this individually as for some patients, labelling glasses may be embarrassing.
- Write instructions, for example, about eye-drops, especially if someone is forgetful or confused. These may need to be given to a carer or relative.
- While written instructions can be a good tool for some, be guided by the individual situation as some patients may find this embarrassing or demeaning.
- Patients may have trouble naming things or speech problems, or may forget letters, so try animal pictures instead of the Snellen chart, as used for children.
- If still unable to articulate, be flexible, creative and give directions they can follow such as placing items on a tray and asking them to pick up something or point to the blue object.
- Posture and behaviour provide hints about eyesight. If their head is right down on the tray looking for something, their eyesight may not be good.
- Unusual behaviour—becoming withdrawn, confused or disoriented, being clumsy, bumping into things, falling more, holding things close or being startled by noises or people approaching—may be a reaction to sight loss.
- Be aware that some medication taken by dementia patients, including antipsychotics, anticholinergics and some antidepressants, can cause blurred vision. Carers can offer observations.
- Some forms of dementia are characterised by resistive and uncooperative behaviour due to impaired concentration, comprehension and judgement. Use a kind and caring approach.
SOURCE: Helen Venturato and Dr Ruth Kipen
Tagged as: Eye examinations, Patient management